Integrating emergency general surgery with a trauma service: impact on the care of injured patients.

Abstract

There has been considerable discussion on the national level on the future of trauma surgery as a specialty. One of the leading directions for the field is the integration of emergency general surgery as a wider and more attractive scope of practice. However, there is currently no information on how the addition of an emergency general surgery practice will affect the care of injured patients. We hypothesized that the care of trauma patients would be negatively affected by adding emergency general surgery responsibilities to a trauma service. Our institution underwent a system change in August 2001, where an emergency general surgery (ES) practice was added to an established trauma service. The ES practice included emergency department and in-house consultations for all urgent surgical problems except thoracic and vascular diseases. There were no trauma staff changes during the study period. Trauma registry data (demographics, injuries, injury severity, and procedures) and performance improvement data (peer-review judgments for all identified errors, denied days, audit filters, and deaths) were abstracted for two 15-month periods surrounding this system change. Chi-square, Fisher's exact, and t tests provided between-group comparisons. The trauma staff evaluated a total of 5,874 patients during the 30-month study. There were 1,400 (51%) trauma admissions in the pre-ES group and 1,504 (48%) in the post-ES group, of which 1,278 and 1,434, respectively, met severity criteria for report to our statewide database (Pennsylvania Trauma Outcome Study [PTOS]). There were 163 (12.7% of PTOS) deaths in the pre-ES group compared with 171 (11.9% PTOS) deaths in the post-ES group (p = not significant [NS]). There was one death determined to be preventable by the peer review process for the pre-ES group, and none in the post-ES group. Both groups had 10 potentially preventable deaths, with the remaining mortalities being categorized as nonpreventable (p = NS). Unexpected deaths by TRISS methodology were 36 (2.8%) and 41 (2.9%) for the two groups, respectively (p = NS). There was no difference in the number of provider-specific complications between the groups (23, [1.8%] vs. 19 [1.3%], p = NS). The addition of emergency surgery has resulted in an additional average daily workload of 1.3 cases and 1.2 admissions. Despite an increase in trauma volume over the study period, the addition of emergency surgery to a trauma service did not affect the care of injured patients. The concept of adding emergency surgery responsibilities to trauma surgeons appears to be a valid way to increase operative experience without compromising care of the injured patient.